New law could expand role of pharmacists as health care providers

A bill signed into law last month by California Governor Jerry Brown and taking effect on January 1, 2014 could be an important first step toward changing how pharmacists practice, especially in community settings.

The legislation also establishes a new Advanced Practice Pharmacist who—with specified advanced training and experience, Board of Pharmacy recognition, and in collaboration with a patient’s primary care provider—will be allowed to assess and refer patients; start, stop, and adjust drug therapies; order and interpret drug therapy-related tests; and “participate in the evaluation and management of diseases and health conditions.”

Perhaps most significantly, the bill declares “pharmacists are health care providers who have the authority to provide health care services.” Such provider status legislation could allow more pharmacists to practice “at the top of their license,” that is, to the full extent of their training and education, with a potentially major effect on practice and payment models.

How did this new law come about? Why this change in pharmacist provider status now?

With the Affordable Care Act, we’re going to have millions of people who haven’t previously been insured. We also have an escalating number of baby boomers becoming eligible for Medicare every day—and that aging population includes an increase in patients with chronic conditions taking multiple medications.

So add to this the primary care provider [physicians] shortage and you have this perfect storm. Everybody started to look around and ask, ‘How are we going to take care of all these people?’ So Senator Ed Hernandez [author of the new law, Senate Bill 493] was very forward-thinking.

With an estimated 32,000 practicing pharmacists in California vs. (as of 2008) about 23,000 primary care physicians, how will this increase the health system’s capacity?

When you look at having that many more providers [after the law and Board protocols go into effect] offering vaccinations, helping people stop smoking, and able to provide hormonal contraception, that’s a huge number.

This new law addresses many pain points within the public health system: Historically, it has been, ‘How do we get everybody vaccinated?’ Inability to vaccinate the population has been a public health crisis. Well, the perfect place is the pharmacy, a place with readily accessible clinicians. And patients go to pharmacies far more often than they get to their primary care provider. So, likewise, with smoking (another public health crisis) and with contraception, community pharmacy is starting to expand its scope of practice in areas where the need is greatest.

Some state pharmacists already work under collaborative practice agreements with medical practices, or on patient care teams in hospitals and outpatient clinics. They already do medication therapy management: working with patients to ensure they get the best results from their medications, dealing with drug access, interactions, and adherence issues. So what’s the big difference under this new law?

While collaborative practice agreements are common in health care systems [hospitals, ambulatory care clinics] they are not prevalent today in the community setting, outside of vaccinations. Traditionally, and still right now, community pharmacists have been seen as and paid for delivering a product. Community [retail] pharmacies have been product-based practices. This bill views pharmacists as providing health care services and really underscores that this is the capability of the pharmacist.

There are so many patients who need help out there that we need to be working with all the other health care professionals, with everyone working to the top of their licenses.

So should we now expect pharmacists to start hanging out their own shingles in free-standing clinics and offering medication management services?

We don’t want pharmacists to be isolated practitioners. We want them to be part of team-based care, using their medication management skills to improve the care of the patient. The goal is the co-management of the patient with the primary provider.

A common example would be medication for high blood pressure. Under most guidelines, patients should return to their physician within two weeks for follow-up if they have been started on a new blood pressure medication, but that often doesn’t happen.

If those patients could be managed in the community pharmacy, so they are seen within two weeks, get their blood pressure checked, their medicine titrated [adjusted], and this gets communicated back to the primary care provider, then all parties know what the other is doing and that care is shared.

There are multiple studies showing that patients who work with both a pharmacist and a physician on a team are more likely to achieve blood pressure goals than those who don’t have a pharmacist. It can be the same for other diseases: Let the physicians diagnose and start treatment, and let the pharmacists titrate and help people reach their therapeutic goals. There is no shortage of work for all of us.

Beyond some additional services pharmacists can deliver independently, this law’s newly recognized Advanced Practice Pharmacist will still need to work in collaboration with patients’ primary care providers. How do you see such arrangements being implemented more widely?

It has to be done by building relationships with primary care providers, finding out their pain points that are medication-intensive—the points at which they’re bursting at the seams and can’t manage.

Take the PRICE clinic [Pharmacists Review to Increase Cost-Effectiveness, started by Stebbins at the Sacramento-based Mercy Medical Group and at San Francisco General Hospital]; this was based on a pain point where patients couldn’t afford their medications.

As pharmacists in these clinics, we told the physicians, ‘Let us help. We’ll get patients on more cost-effective drugs, Medicare plans, free drug programs.’ The second a patient brought up cost, they were referred to our clinics. Physicians didn’t have to spend 20 minutes on an area they didn’t really know how to optimize.

Community pharmacists have to identify those physician pain points that will allow primary care providers to practice more efficiently. Because it’s got to be a win-win: we help the patients by helping the physician, and we expand our scope of practice.

The new law authorizes pharmacists to “participate in multidisciplinary review of patient progress, including appropriate access to medical records” and predicates most Advanced Practice Pharmacist services on coordination with prescribers. What are the challenges to implementing that?

Pharmacists are going to need information, and they will have to share information with the primary care providers. But that’s where it becomes very tricky, because pharmacies don’t have access to the EMR [Electronic Medical Record]. Everybody’s so worried about privacy, compliance, and protection, and we are not set up very well to share data electronically. And that will be the most important thing if this is going to work: How will the information be exchanged so that when a pharmacist gives a vaccination, this becomes part of the patient’s medical record? Or how does the change in a patient’s blood pressure medication that occurs at the pharmacy get into the primary care provider’s medical record?

How does this legal declaration that pharmacists are health care providers affect their ability to get paid for providing services?

This was a very necessary first step to get the status of a provider. But this bill does not talk about payment.

A logical next step would be to go to Medi-Cal [California’s Medicaid program] and say, ‘The state has recognized us as providers; will you pay for these particular pharmacy services?’ So, for example: ‘Will you pay for smoking cessation counseling? Will you pay for the initiation of hormonal contraception? Will you pay for medication therapy management?’

So that’s a real key factor going forward. This isn’t tied to payment. How do we become providers in the Medicare and Medicaid systems? Then there’s a professional fee schedule and we’re providing services, not just products. And that’s what we really need to do as a profession.

How will payment of pharmacists as health care providers fit into the emerging model adopted by Medicare and others, in which medical groups, HMOs, and hospitals are paid per patient (capitation), with added bonus payments if certain patient health outcomes are met?

Suppose a group medical practice will get paid extra for helping patients with diabetes get their blood sugar levels under control. If they get paid for that, that’s not necessarily a physician getting paid, it’s the group. And the group figures out who’s going to provide that service. Now that pharmacists are considered care providers and are experts in medication management, why not have them help fill this role?

So is it less expensive to have pharmacists provide—and be paid for providing—more health care services?

Pharmacists aren’t cheap, but it would be more cost-effective to have everyone working at the top of their license. So a physician isn’t doing something that a pharmacist is better trained to do, and pharmacists aren’t doing something that is within a nurse practitioner’s scope of practice.

Patients would get the care they need from the most appropriate providers. These providers may be nurses, pharmacists, and/or social workers, allowing physicians to see more patients, and doing what only physicians can do—which is diagnose. Let pharmacists take on a larger role in medication management, while other health care providers do what they are best trained to do.

Ultimately, how significant do you consider this new law to be?

This bill could help change the face of pharmacy. This is a really big deal, especially for community pharmacists—this challenges them to step up and become providers of care. It’s the redefinition of community pharmacy. This bill says, ‘California, this is what your pharmacist can do.’

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Summary of the Pharmacist Provider Status Law (SB 493)

Under the new pharmacist provider status law, Senate Bill 493, and pending relevant California State Board of Pharmacy protocols, all state-licensed pharmacists will be authorized to:

Furnish hormonal contraceptives, prescription nicotine replacement products for smoking cessation, and prescription medications not requiring a diagnosis that are recommended for international travelers

Independently initiate and administer certain routine specified vaccinations, as well as give other prescribed drugs by injection

Order and interpret tests to monitor and manage the effectiveness and toxicity of drug therapies, in coordination with the patient’s primary care provider

In addition, the law establishes an Advanced Practice Pharmacist (APP), to be recognized and regulated by the State Board of Pharmacy. Pharmacists meeting the APP criteria are authorized to:

Perform patient assessments

Order and interpret drug therapy-related tests

Refer patients to other health care providers

Participate in the evaluation and management of diseases and health conditions in collaboration with other health care providers

Initiate, adjust, or discontinue drug therapy-as long as they promptly notify the patient’s diagnosing prescriber in writing or enter the information in a patient record system shared with the primary care provider

In order to earn APP recognition by the State Board, a state-licensed pharmacist would need specific training and patient treatment experience that meet two out of these three criteria:

Completed a postgraduate residency program through an accredited institution where at least 50 percent of the experience includes direct patient care with interdisciplinary teams

Provided clinical services to patients for at least one year under a collaborative practice or protocol with a physician, advanced practice pharmacist, pharmacist practicing collaborative drug therapy management, or health system

Analysis proposes greater role for non-physicians in primary care

Even as the state law potentially expanding pharmacists’ roles goes into effect, a new analysis proposes solving an impending national shortage of primary care providers by creating physician-led patient care teams of health care personnel who are empowered to provide an expanded scope of care.

The article in Health Affairs, co-authored by UCSF School of Medicine faculty member Thomas Bodenheimer, MD, MPH, notes, “It is possible that 24 percent of [primary care physician] clinician time could be saved by sharing the care among a primary care team. The registered nurse and pharmacist workforces are sufficient to add primary care capacity.”